February 2025 – Risk Managers

ful.CashPay

Introducing ful.CashPay – The app that helps users learn, shop and save on healthcare

N.C. Teachers, State Employees Voice Frustration Over State Health Plan

“If the state had followed Folwell’s recommendation to adopt Reference Based Pricing a few years back they wouldn’t be facing a rate increase and a +$1 billion health plan deficit next year. Instead, the state changed the logo on their health insurance card.“ – Bill Rusteberg

Texas Reference Based Pricing

We have been managing self-funded Reference Based Pricing plans in Texas for more than two decades, from North Texas to South Texas, From West Texas to East Texas.

Certain regions in Texas provide a better environment than others for Plan Sponsors interested in breaking away from 40+ years of a failed health care delivery system.

John and Anne Darwin – The Case of The Canoe Conman

One of the most infamous cases of life insurance frauds is that of Brit couple John and Anne Darwin, whose notoriety has inspired several documentaries. Drowning in debt, the couple realized that their obligations would be wiped out if John faked his own death. Anne helped her husband in doing so in 2002, when John reportedly disappeared in a canoeing accident.

Dr. Donny Prescribes High Dose Suppositories For Hospital Administrators

Hospital Administrator Reacts To Trump’s Executive Order

“By signing this form you agree to pay our secret prices when you receive our bill a few months from now or we will repossess your first born, your car and bass boat, and garnish your wages until full payment is made.” – Your Faith based Non-Profit & Charitable Hospital

“Bend over while I insert a high dose Executive Order suppository!” – Doctor Donny

Cash Pay Healthcare Financing

Imagine expanding your corporate card program to include Cash Pay Healthcare financing through a dedicated virtual Cash Pay Healthcare card.

Challenges with Ineffective PBM Clinical Management for Specialty Drugs

“Is your PBM’s Prior Authorization – promise to perform – a myth, a fictional novel with a sad ending, entitled ‘Gone With The Wind’ or is it active, robust and effective? The answer may surprise you.” – Bill Rusteberg

High Hospital Reimbursements Are Bad For Our Health

“This fact illustrates that high employer reimbursements are enabling most hospital systems in America to remain reactive and not focused on preventing disease. Only when those high employer reimbursements are scarce will hospitals change.”

Why Is Selling in Healthcare So Hard??

By Eric Bricker

Why Is Selling in Healthcare So Hard?? Digital healthcare startups and healthcare services companies that sell to employers have a difficult time selling because it is a complex business-to-business (B2B) sale.

Government Investigates UnitedHealthcare

Federal government examining whether insurance giant is illegally raising Medicare program users’ monthly payments.

Does The TSHBP Disaster Have Anything To Do With SB 1276?

Risk pools haven’t worked out so well for many Texas school districts in the past. The most recent example is the TSHBP risk pool whose short life span violently ended in financial disaster requiring pool members to cough up millions more in unbudgeted assessments to pay for plan shortfalls.

Boon Chapman 2.0

AUSTIN, TX – Boon-Chapman, a leader in claims administration, cost containment, and care navigation, is pleased to announce the appointment of Marcus Kammrath as Regional Vice President, Sales effective February 17, 2025.

Healthcare Smart Card

The rising cost of medical care and lack of access to health financing options is adversely affecting the lives of poor household in India.

Plan Sponsors Can’t Win For Losing

You try to do the best you can do to attract and retain employees. You’ve risked your own money to build your business. You’re self-funded. But then, as government interference in your health plan grew, your risk took on a whole new dimension.

Reported Loss vs Ultimate Loss

Self-funded health & welfare rate setting can be established based on a short or long view.

FDA Declares Semaglutide Shortage Over, Spelling End To Compounded GLP-1 Market

The Food and Drug Administration on Friday announced that semaglutide, the active ingredient in weight loss drugs Ozempic and Wegovy, is no longer in short supply.

Court Rejects Provider’s Request to Block Surprise Billing IDR Decision

“The surprise billing IDR regulations remain in flux. Nevertheless, this air ambulance provider’s claim ignores the NSA’s threshold coverage requirement that must be met before initiating the IDR process.”

Understanding Hospital Charges, Costs and Payments

“Hospital costs vary according to how much they must spend to provide patient care, as opposed to how much a patient or insurer must spend to receive care.”

DOJ Investigates Medicare Billing Practices at UnitedHealth

The Justice Department has launched an investigation into UnitedHealth Group’s Medicare billing practices…….UHC stock prices rocked – see live quote here.

Rx Prices That Will Make You Sick

If you are a Plan Sponsor wondering if your PBM provides the best prescription drug pricing wonder no more. You’re most probably not. A Canadian pharmacy has your back.

Significant Damage Awards And Settlements Impacting Educational Institutions

Article Referred By Jeff Evans – Risk Manager

JUST RELEASED – Large Loss Report 2025

United Educators’ (UE’s) annual Large Loss Report highlights major damage awards and settlements affecting educational institutions in the previous year.

Curative Public Sector Webinar

Cutting Costs with Better Benefits: A Solution to Public Sector Healthcare

Say goodbye to the frustration of cookie-cutter healthcare plans. Join us for an insightful webinar on Wednesday, March 5th, at 1:00pm CST led by Fred Turner, CEO of Curative, as he shares a common sense approach to public sector health coverage that cuts costs while offering richer benefits.

We Spend Less On Rx Than You!

The Nueces County self-funded health plan bases medical claim payment through a PPO managed care contract while Rx claims are paid through a traditional PBM payment model.

Unemployment Looms For Death Bed PPO’s & Other Third Party Leeches

“I just had a meeting with my tech company. You have no idea how close you are to having AI displace most of you.”

How This Employee Lost 100 lbs Using His Employee Benefits

By Lee HafnerFebruary 19, 2025

Robert Flores spent nearly 30 years on a roller coaster regimen of diets and exercise programs, losing weight only to gain it all back and start again.

ICHRA – A Transformative Force Challenging The Status Quo

By Michelle Mead

ICHRA stands out as a transformative force that challenges the status quo of traditional group plans. Removing the endless cycle of health insurance renewals and their yearly increases.

Association Health Plan Since 1965

The ACEC Life/Health Trust is a non-profit Association Health Plan governed by a board of Trustees elected by ACEC Life/Health Trust Member firms. Our mission is to provide exclusive, high value health care benefits to ACEC Member firms to support the health and well-being of their employees and families.

Helping Patients Take Ownership In Their Health

By Nisha Chellam, M.D.

A few years ago, when I quit insurance, I found myself drowning in debt. I went from 1000 patients to “0” patients.

Reference Based Pricing Plan With The Guarantee Of No Balance Billing

Choose Any Provider With The Freedom Plan

The Freedom Plan options allow a full choice of health care providers without restrictions or penalties. There are no preferred providers or networks required. Members see the provider they choose!

Health Systems Claim “Tight Margins”—But Are They Really?

By Dutch Rojas

Health systems love to say their margins are razor-thin. But when they do, they’re only talking about operating margins—the money they make (or lose) from patient care alone. What they don’t include tells a very different story.

COVID-Crusader Cites Cost Of Being Labeled ‘Dangerous’ By The Texas Medical Board

Kellen McGovern Jones – Senior Investigative Reporter

There is a cost to defending yourself against the Texas Medical Board, and it is far from cheap.

How To Make A Few Extra Bucks In 10 Easy Steps

Video shows as the woman was driving on the busy highway when another car cut her off and caused her to slam on the brakes.

Aldeen’s Sunday Morning Bathroom Read

By Doug Aldeen – ERISA Healthcare Attorney and General Counsel – Visit my website

In a significant win for Texas pharmacists and their patients, Texas Attorney General Ken Paxton issued a long-awaited opinion on Wednesday regarding two key pharmacy benefit manager (PBM) reform bills enacted in 2021 that are intended to curb abusive practices by PBMs.

Where Sun Life Sees Stop-loss Problems Risk Managers See Stop Loss Solutions

“When your Reference Based Pricing Plan is pooled with traditional managed care plans you are subsidizing those poorer risks with a premium load you don’t deserve. You receive very little underwriting credit. That doesn’t happen when pooled with other groups practicing the same cost effective strategies. Where Sun Life sees stop loss problems Risk Managers sees stop loss solutions” – Bill Rusteberg

PCM Unveils Updated Analytics Platform

Prescription Care Management Unveils Updated Analytics Platform

Source: Prescription Care Management (PCM), 02/13/2025

RENO – Prescription Care Management (PCM), a leader in benefit plan data solutions, is pleased to announce the release of its updated PCM Platform, featuring integrated pharmacy and medical data, a new Dynamic Report Builder and easy-to-interpret data visualizations and dashboards.

What Do Gila Monsters Have To Do With GLP-1 Drugs?

After learning that the venom of a Gila monster lizard contained hormones that can regulate blood sugar, Daniel Drucker started wondering why. And could the venom somehow help treat diabetes?……..…ten years later a synthetic version of a hormone in the venom became the first medicine of its kind approved to treat type 2 diabetes. Known as a GLP-1 (for glucagon-like peptide-1) receptor agonist, the medicine set off a cascade of additional venom-inspired discoveries.

Tom, Dick, Harry and Mary

“Thank goodness I have Computer Accessory Insurance (CAI)! This only costs a $35 co-pay!” gloats Tom. “I saved $37.99!”

“Shoot Tom, looks like I have better CAI! My company insurance pays for everything as long as I play by the rules! Says Dick.

“Rules? What rules?” says Harry

OMG! Another Cash Pay Health Plan Vendor

WHAT IS APTA CASH?

Apta Cash can help you save on medical expenses by choosing vetted, high-quality, medical providers who offer affordable cash prices for their services. Not only does paying cash eliminate the need for time consuming administrative work, but the providers are paid much quicker using Apta Cash. It’s a win-win for everyone!

Connecting You With The Largest Cash Pay Marketplace

The business of healthcare has become a rough road to travel. It’s time for a better healthcare transaction!

Family says Cincinnati Children’s won’t put unvaccinated daughter on heart transplant list

By Victoria Moorwood – Cincinnati Enquirer

This story has been updated to include the family’s religious beliefs and a statement from the National Institutes of Health. Here’s the latest news on the controversy.

Cash Pay Health Plan I.D. Card

This is a Cash Pay Health Plan I.D. card. It works better than yours………………

Lawmakers seek ‘innovative’ health options as Texas leads nation for most uninsured residents

For three years in a row, Texas health insurance premiums have increased by over 5% annually, according to the Texas Association of Health Plans. Advocates are calling on the Texas Legislature to cut certain insurance regulations and expand Medicaid eligibility to help close coverage gaps. (Courtesy Adobe Stock)

Article Referred By Jody Bright

By Hannah Norton

About 5 million Texans, or 16.4% of the state population, did not have health insurance in 2023, according to data from the U.S. Census Bureau. Texas’ uninsured rate was higher than any other state and more than twice the national rate of 7.9%.

Does Mary’s ASO Contract Contain Impermissible Gag Clauses?

“Who Me? I Didn’t Approve The Agreement! Our Consultant Did!”

Mary is in hot water. She denies she signed the Blue Cross ASO Agreement. Meanwhile her insurance consultant is at home reading his E&O policy…………..

Plan sponsors should be aware that Gag Clauses by statue prohibits any restriction on accessing data. “Any limitation on the scope, scale, or frequency of electronic access to de-identified claims and encounter information or data is considered a [prohibited] restriction. Electronic access for plans and business associates is required to be available on request.”

Eyeing Cost and Flexibility, More Employers Opt for Alternatives to Traditional Health Plans

“One option gaining traction is the Individual Coverage Health Reimbursement Arrangement (ICHRA), which saw adoption surge by 29% among small employers and 84% among large employers from 2023 to 2024[.]”

Kennedy Wins, Medical Industrial Complex Loses

It’s official.

Laughter Is The Best Medicine

Comedian spots former high school football team member in the audience.

Doctors & Libertarians Wanted To Be Left Alone

By Dutch Rojas

Doctors and Libertarians Wanted to Be Left Alone,
But the Activist Judges, Bureaucrats, and MBAs Had Other Plans

Why The Health Care Industry Is Letting RFK Jr. Cruise To Confirmation

Robert F. Kennedy Jr. campaigned for Donald Trump after dropping his own presidential bid in August. | Anna Moneymaker/Getty Images

By Daniel Payne

From drugmakers to doctors, few health care groups are asking senators to block Robert F. Kennedy Jr. from becoming HHS secretary.

Robert F. Kennedy Jr.’s expected Senate confirmation on Thursday to lead the nation’s health agencies threatens upheaval for America’s $4 trillion health care industry.

The DPC Menu

Look, Up In The Sky! It’s A Bird, It’s a plane, It’s a……DPC Physician!

Direct Primary Care (DPC) centered health plans are growing in number for a lot of reasons. Primary care physicians, under the thumb of insurance companies, want their freedom back. Patients want easier, quicker, unlimited access and more time with their doctor. Plan sponsors see direct primary care physicians as their “In-House” risk manager tasked with managing all upstream care towards best-in-class specialty care with lower cash-like pricing. The article below is a great read for all these stakeholders.

Selling and Destroying Relationships

Selling health insurance is a tough business. It’s not a created sale, it’s a replacement sale which means relationships must be destroyed before any chance of a sale is possible. Destroying relationships takes time, effort and money. The sales cycle is long.

The Bigger You Are The Bigger The Overhead

The smaller you are the smaller the overhead with savings passed on to clients by independent fee-based insurance consultants who have access to more resources than legacy brokerage firms hobbled by internal resources which often pose conflict of interest difficulties at the expense of their clients.

California’s Insurer of Last Resort Runs Out of Money To Pay L.A. Fire Claims

In the aftermath of the fires, the FAIR plan will get a $1 billion bailout — the latest indication that California’s home insurance market is on shaky footing.

Sex, drugs And Underlying Health Issues: The Crippling Cost of Insuring Old Rockers

Rock’s biggest stars are opting to tour without insurance rather than spend a fortune on ‘non-appearance’ cover. But it’s a risky strategy

The Evolution of Reference Based Pricing

Our experience with Reference Based Pricing beginning almost two decades ago passed through three stages:

FTC Releases Second Interim Staff Report on Prescription Drug Middlemen

Report finds PBMs charge significant markups for cancer, HIV, and other critical specialty generic drugs

TPA’s Provide Customer Service

INSURANCE AGENT: Recently we have noticed a spike in inquiries from plan members regarding benefits and claims. Your third party administrator, as part of their contractual obligation, has customer service representatives standing by to assist your membership during regular business hours.

EVO First

TAKE CONTROL OF YOUR PHARMACY SPEND – Know your benefits. Know your costs. Get your rebates.

Risk Managers Risk Pool

Risk Managers Purchasing Cooperative offers Participating Employers membership in a proprietary stop loss insurance risk pool designed to better manage their Benefit Programs’ stop loss risk.

FMMA Annual Conference: The Direct Care Game Changer

The healthcare monopoly is over. Join us at the FMMA Annual Conference, where forward-thinking physicians, employers, public sector leaders, and benefits experts drive healthcare transformation.

This Is How Carriers Skirt The MRL Mandate

“In a highly vertically integrated healthcare organization like UnitedHealth Group, this technicality becomes a powerful tool to obscure how internal transactions inflate profits, consolidate market power, and ultimately drive up costs for patients and employers.”

Choose Any Provider With The Freedom Plan​

WHAT IS APTA CASH?

Choose Any Provider With The Freedom Plan